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Nicole Nolan MD

Radiation Oncology Methodist Health System

Cancer.org 2019 stats

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Rates have been decreasing from 2005 to current

Mortality has been declining since 1990 again due to smoking declining

RF-#1 is SMOKING, 80% of all lung cancer deaths are due to this one risk factor

#2 Radon Gas

Cancer.org 2019 stats

Screening!!!!!

First screening trial looked at CXR to detect lung cancer it failed.

Second trial looked at CT scans to screen a specific subset of patient and this showed BENEFIT. This noted a 20% reduction in mortality when compared to CXR screening.

Who? USPTF Grade B Current or former smokers—former have to

be less than 15 years out from quitting

Age 55-80

Have at least 30 pack year hx-pack year hx is calculated by how many packs per day times years smoked.

Example: 2 packs per day for 40 years is 80 pack years.

NOT everyone who fits this should get a scan other factors must also be taken into acct—such as overall health, if we find something could they go through a treatment for cancer? More on this later

Category B means they recommend this service.

Cancer.org 2019 statsUnitedstatespreventiveservicetaskforce.org

Subtypes

NSCLC-appox 80%

Squamous Cell-30% of all Lung Cancers

Adenocarcinoma—40% of all Lung Cancers

Large Cell-9% of all lung cancers

SCLC-appox 15%

Misc-5%

Carcinoid

Sarcomatoid

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NSCLC(non small cell lung cancer) Largest subset of lung cancer

Adenocarcinoma

This is the most common histology

Smokers and non smokers

Normally seen in the periphery of the lung

Tends to grow slower than other histologic subtypes

Squamous Cell Carcinoma

Second Most Common Histology

Most people are smokers

Tends to be more centrally located in the lung

Large Cell(undiff carcinoma)

Typically very fast growing and aggressive

Outcomes are very poor

Can grow anywhere in the lung

More like a small cell lung cancer

http://www.cancer.org/cancer/lung-cancer.html

SCLC(small cell lung cancer)

Exclusively a smokers lung cancer

Grows quickly, very aggressive

Typically centrally located, often present with large scale lymphadenopathy in the central chest

Other

Carcinoid

Rare, come from neuroendocrine cells

Typically have a very indolent course

Sarcomatoid

Rare-look like sarcomas

Very Aggressive

Treated differently everywhere due to lack of large clinical trials

Typically can only be curable is surgery is possible

http://www.cancer.org/cancer/lung-cancer.html

STAGING

Staging is very important!

People ALWAYS like to jump the gun

We looked at lung cancer, I told you almost every variant is AGGRESSIVE

Lung cancer likes to spread to other regions, we need to know where it has gone

Staging

PETCT---CORNERSTONE of staging for lung cancer

MRI brain-Lung cancer LOVES to spread to the brain

PFTs-Pulm function tests

CT chest with Contrast

EBUS/bronchoscopy

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Staging helps us decide what is the most appropriate treatment for a patient, someone who has Stage I disease will be treated very differently that someone who has Stage IV disease, take a look at the NCCN guidelines---Stage IV disease is VERY COMPLICATED and it is changing every day with new drugs and targets

Only certain treatment modalities are appropriate with certain stages

Stage IA and IB

T1N0=IA

T2aN0=IB

Treatment

IA

First question is the person a surgical candidate?

If YES the patient should have lobectomy+LN assessment

Some CT surgeons would argue they dont need a lobectomy but lobectomy is considered the gold standard in this country today

If NO, then SBRT(SABR)

What is SBRT-Steriotactic Body Radiation Therapy

High dose, low fraction radiation directed at the tumor to ablate it

Not everyone is a candidate!

Local Control is >93%!

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SBRT

High dose ablative radiation

Used when someone can’t have surgery

This is NOT traditional lung cancer XRT

Most people get very few side effects

Dose is chosen based on where the lesion is in the lung

Not everyone can have this done and we will talk about the caviots

Side effects also come based on what is near by

First step is CT simulation

This is the model of the patient that all treatments will be planned off of.

This is a VERY important step especially in SBRT

Want to be as accurate as we can—reproducability in the set up is VERY IMPORTANT

SBRT cont

CT simulation cont

Most use an alpha cradle system for set up.

Goal is to immobilize the patient, hitting a moving target is IMPOSSIBLE

4DCT—***

Patient marks

Treatment planning

Virtual Simulation—run the plan on a fake patient to ensure what you think you planned is what is being delivered

Start treatments

Truebeam video

https://www.youtube.com/watch?v=UN8a4VGXcf8

What dose, how many treatments?

Depends on where the lesion is in the chest—ie what is next to it that can be damaged---heart/aorta/trachea/bronchi/brachial plexus/liver/spinal cord/rib/chestwall

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Dose, how many tx?

Goal is to get a BED of >=100Gy total. To give you a reference if this was a Stage III lung cancer where SBRT is not possible, the dose for that is 60Gy in 30 fx, much less, because again you have to think about what you are going to damage, 100Gy is A LOT of dose.

This is an IDEAL location, now as luck has it we RARELY get one like this, but this would be safe to treat in 3 fractions of radiation, dose is 54Gy in 3 fractions, 18Gy per fraction, BED=151.2Gy

Now I know you are thinking I thought she just said 100Gy BED, that is the catch the Biological equivalence dose is >100, see equation this is how when we go higher than 1.8-2Gy per fraction you calculate the equivalent dose.

YES there is an APP for that!

What is it is peripheral by the rib?

Have to fractionate differently.

Ribs are pretty robust but with too much dose you can get a rib fracture, take A LOT of dose but with these high doses it can happen and that is a side effect I will consent people for, they have to take that risk, risk in reports is all over the place from as low as 3% to as high as 70%.

I did both of these 50Gy in 5 fractions, decreasing the dose per fraction is gentler on the rib. With both cancers abutting the chestwalland rib, I told them both there is 50% chance the SBRT could cause a rib fracture and chestwall pain bcwhen the tumor is abutting the chestwall the risk goes up.

BED for this is 103Gy

What if it is central—by the heart/aorta/trachea/bronchus/spinal cord

Unfortunately not all of these people can get SBRT, the mass is abutting the VB, I cant do SBRT because I will paralyze you.

If it is right next to the mainstem bronchus or carina I cant do SBRT---this was recent looked at on trial and there were grade 5 toxicity meaning people died from the radiation toxicity. So you have to know when its ok and when it isnt.

If it abuts the aorta—this is a tricky situation, sometime you can do it but most of the time you wont know until you plan, the aorta can take some high doses but only to a limited volume

The top picture I was planning 5 fractions but the dose was too high, patient was not a surgical candidate and ablation was not possible due to location. So when this happens I will do pseudo SBRT, 60Gy in 8 fractions, you can meet the aorta dose and still get good response/control. BED for this is 100Gy.

DO NO HARM FIRST

This is a T4 tumor—mediastinal invasion NOT a candidate for SBRT

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So in summary Stage IA and IB

T1N0=IA

T2aN0=IB

Not everyone is a candidate for SBRT

The only person who can decide is the RADIATION ONCOLOGIST

SETUP and PLANNING VERY IMPT

Side effects come from what is near by.

Radiation does not cause all of a patients issues!

This is often a dilemma, tumor is large, 5cm, and it moves when the patient is breathing and sometimes it isn't safe to treat that much lung to very high doses.

This is a case by case decision, decided by the radiation oncologist!

If cant do traditional SBRT can try for pseudo-SBRT 60Gy in 8 fx, but if you cant meet the lung dose constraints, then the plan is NOT safe then you cannot do it.

The larger the tumor the more likely it is to be next to something impt as well(ie heart ect).

Often these people will get standard fractionation CRT

What are the survival estimates?

The more advanced disease you have the lower the survival estimates are

This is why lung cancer screening is VERY IMPORTANT. The earlier you find a cancer the more likely someone will survive this. This about breast cancer and mammograms, mammogram completely changed breast cancer.

Overall Survival

-Definition is the length of time from treatment to death(death can be from any cause)

-Most Clinical Trials use this as their primary endpoint but it doesn’t tell the whole story

Cancer Specific Survival

This is the proportion of people that have not died because of cancer

OS survival by Stage NSCLC 5yr OS

IA1-90%

IA2-83%

IA3-77%

IB-68%

IIA-60%

IIB-53%

IIIA-36%

IIIB-26%

IIIC-13%

IVA-10%

IVB-<1%

Important to remember that the landscape of lung cancer treatments are changing every day, likely these numbers will go up due to better therapies but the reality is that lung cancer kills

Look at just the difference in the IA group, the smaller your tumor and less advanced disease->better OS.

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